Autopsy

• 1. Introduction

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  Autopsy begins with a question: how did this person die? The word itself comes from the Ancient Greek autopsia, meaning "to see for oneself," and it has carried that meaning since around the 17th century. At its most basic, an autopsy is a surgical procedure in which a trained pathologist dissects a corpse to determine the cause, mode, and manner of death. But the procedure reaches further than that single question. It can uncover disease processes that were invisible during life, correct mistaken diagnoses, and protect the living from hazards the deceased unknowingly carried. A large meta-analysis found that approximately one-third of death certificates contain errors. Half of all autopsies turn up findings that were not suspected before the person died. Those numbers raise a harder question: how much do physicians actually know about why their patients die? And they prompt another: if the autopsy is such a powerful tool, why are so few performed today?

• 2. Four Kinds of Examination

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  Forensic pathologists at the Scotland Yard Office of the Forensic Pathologist investigate every unnatural death, including accidents, homicides, and suicides. That office emerged during the turn of the 20th century as forensic science began to develop more formally. The forensic autopsy is the most legally charged of the four main types. It seeks the cause and manner of death and tries to identify the deceased. Medical examiners look for time of death, exact cause, and what may have preceded death, such as a struggle. Toxicology tests run on biological specimens can detect chemical substances in the body, though post-mortem deterioration and the pooling of bodily fluids can cause those tests to overestimate rather than underestimate the quantity of a suspected compound.

  Clinical autopsies serve hospitals in a different way. They probe the mechanisms of disease and verify whether the standard of care was met. Within the United Kingdom, clinical autopsies require the consent of the deceased's family, unlike a medico-legal autopsy ordered by a Coroner in England and Wales or a Procurator Fiscal in Scotland, which the family cannot refuse. Over time, clinical autopsies have led to the discovery of conditions including fetal alcohol syndrome, Legionnaire's disease, and viral hepatitis.

  Academic autopsies exist for a narrower purpose: giving medical students and residents direct experience with anatomy and pathology. They demand skill in connecting anatomic findings to clinical history, because they involve organ systems and the interruptions caused by both pre-death and post-death processes.

  Virtual autopsies, conducted using magnetic resonance imaging and computed tomography, examine the body without dissection. They offer one concrete advantage: they do not expose the examiner to biohazardous materials that may be present inside the body.

• 3. Reading the Body

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  A body arrives at a medical examiner's office, municipal mortuary, or hospital in a body bag or on an evidence sheet. A new body bag is used for each body so that only evidence from that individual is contained inside. If examiners believe significant evidence may be present on the hands, such as gunshot residue or skin beneath the fingernails, a separate paper sack is placed around each hand and taped shut at the wrist.

  The external examination comes first. The person responsible for handling and moving the body is called a diener, a German word for servant. In the United Kingdom, that role belongs to an Anatomical Pathology Technician, or APT, who also assists the pathologist during the internal examination and with reconstruction afterward. The body is photographed, clothing is noted and removed, and external residue and materials are collected. Ultraviolet light may be used to locate evidence not visible to the naked eye. Hair samples and nail samples are taken, and the body may be radiographically imaged. A general description recording ethnic group, sex, age, hair color, eye color, and distinguishing features such as tattoos and old scars is made using a voice recorder or a standard examination form.

  In some countries, including Scotland, France, Germany, Russia, and Canada, an autopsy may consist of the external examination only. This approach, sometimes called a "view and grant," applies when the medical records, history of the deceased, and circumstances of death together are sufficient to establish the cause and manner of death without an internal examination.

  When an internal examination is required, a plastic or rubber brick called a head block is placed under the shoulders so that the chest is pushed upward and the neck is hyperflexed. Several incision patterns are available, including a Y-shaped cut starting at the top of each shoulder and converging at the lower sternum, or a U-shaped incision used typically on women and during chest-only autopsies. All of these incisions extend down to the pubic bone. Bleeding from the cuts is minimal because there is no cardiac activity to drive blood pressure; however, in cases of drowning, anecdotal evidence suggests bleeding can be quite profuse. Shears cut through the ribs at the costal cartilage so the sternum can be removed and the heart and lungs can be seen without disturbing the pericardial sac. A PM 40 knife detaches the sternum from the soft tissue connecting it to the mediastinum.

  Organs can be removed using the en masse technique of Letulle, which takes all organs out as one large mass, or the en bloc method of Ghon, which groups them into four sets. In the United Kingdom, a modified version of the Ghon method is most common. Most pathologists prefer to remove the organs as a single block using dissection of the fascia and blunt dissection with the fingers or hands. Each organ is examined, weighed, and sampled. The stomach and intestinal contents are examined and weighed as well; because food moves through the bowel at a predictable rate, the amount of empty intestine can help establish when the person last ate and, from there, the approximate time of death.

  To reach the brain, an incision runs from behind one ear, over the crown of the head, to a point behind the other ear. The scalp is pulled away in two flaps, one forward over the face and one back over the neck. A circular reciprocating saw cuts a cap from the skull so the brain can be observed in place before its connections to the cranial nerves and spinal cord are severed. If the brain needs to be preserved before inspection, it is placed in a container of formalin, a 15 percent solution of formaldehyde gas in buffered water, for at least two weeks and preferably four. Formalin not only preserves the tissue but firms it, making the brain easier to handle without damage.

• 4. Restoring the Body

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  After the internal examination, reconstituting the body so that relatives can view it is an important part of the procedure. The thoracic cavity is open and empty, the chest flaps are spread on both sides, and the top of the skull has been removed with the skull flaps pulled over the face and neck. To restore the body, the internal cavity is lined with cotton, wool, or a similar material. The organs are placed into a plastic bag to prevent leakage and returned to the body cavity. The chest flaps are sewn closed and the skull cap is sewed back in place. The incision made over the crown of the head is not visible when the head rests on a pillow in an open casket. In the United Kingdom, the Human Tissue Act 2004 requires that all organs and tissue be returned to the body unless the family has given explicit permission to retain any tissue for further investigation. After embalming, it is common for relatives not to be able to tell the procedure was performed.

• 5. A History of Opposition and Discovery

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  Around 3000 BCE, ancient Egyptians were among the first civilizations to remove and examine the internal organs of humans, doing so through tiny slits in the body during mummification, in part because outward disfigurement was believed to prevent the dead from entering the afterlife. Two Greek physicians, Erasistratus and Herophilus of Chalcedon, who lived in 3rd century BCE Alexandria, stand out as notable early practitioners, though autopsies remained rare in ancient Greece overall. In 44 BCE, Julius Caesar was formally autopsied following his murder by rival senators. The physician's report identified the second stab wound as the fatal one. By around 150 BCE, ancient Roman legal practice had established clear parameters for what autopsies could determine.

  Galen, who lived from 129 to around 216 CE, gained most of his anatomical knowledge by dissecting animals rather than humans. His findings went largely unchallenged for over a thousand years, until the Renaissance. In Europe, practitioners who worked with enough regularity to become skilled at preservation were active as early as 1200, filling veins with wax and metals to maintain the body.

  Pope Boniface VIII, who lived from around 1230 to 1303, issued a prohibition against cooking bodies to separate flesh from bone, a practice used to transport the remains of Crusaders home. Many physicians interpreted the prohibition as a ban on any interference with human bodies, and anatomical research declined. In the late 15th century, Pope Sixtus IV issued a bull permitting students at Bologna and Padua to dissect human bodies, reopening the path for figures such as Andreas Vesalius and Giovanni Battista Morgagni.

  Vesalius, born in the Netherlands around 1514 and died in 1564, conducted a public dissection of a former criminal's body in 1543. He articulated the skeleton, producing what is considered the world's oldest surviving anatomical preparation. His text, De Humani Corporis Fabrica Libri Septum, published in 1543, became the foundational work of early modern anatomy. Vesalius paid particular attention to the musculoskeletal system, including more detailed and accurate drawings of those structures than his predecessors had provided.

  In 1679, the Swiss anatomist Theophile Bonet, who lived from 1620 to 1689, published the Sepulchretum, a medical compilation that drew on nearly 450 authors, including Galen and Vesalius, and gathered examples of autopsies from across the history of medicine. Giovanni Battista Morgagni, an Italian anatomist who lived from 1682 to 1771, linked symptoms observed in living patients to the physical changes found in their organs after death. He is celebrated as the father of anatomical pathology. His exhaustive work on pathology, De Sedibus et Causis Morborum per Anatomen Indagatis, published in 1769, recorded those connections systematically.

  In the mid-1800s, Carl von Rokitansky and colleagues at the Second Vienna Medical School began using dissection to improve diagnostic medicine. Rudolf Virchow responded to the general lack of standardization in the 19th century by publishing specific autopsy protocols, one of which still bears his name. Evidence of forensic autopsies dates back to at least the 13th century in Bologna, and the anatomic autopsy gained prominence in Padua before spreading across Europe. Ibn Tufail, a Moorish philosopher and physician who lived from around 1109/10 to 1185/86, discussed autopsy in his treatise Hayy ibn Yaqzan, and scholar Nadia Maftouni has identified him as among the early supporters of autopsy and vivisection.

• 6. The Declining Rate and What Is Missed

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  In most Western countries, the number of hospital autopsies has fallen every year since 1955. In the United Kingdom in 2013, only 0.7% of inpatient adult deaths were followed by a consented autopsy. In Germany, the autopsy rate sits below 5%, a figure the medical journal Deutsches Arzteblatt, published by the German Medical Association, has described as a product of governmental reimbursement that barely covers costs. By contrast, Sweden and Finland maintain rates of 20-30%. In the United States, autopsy rates fell from 17% in 1980 to 14% in 1985 and then to 11.5% in 1989, though the figures vary considerably from county to county.

  Pathologist and former JAMA editor George D. Lundberg has argued that the reduction in autopsies is negatively affecting hospital care, because when mistakes lead to death, they often go uninvestigated and lessons remain unlearned. A systematic review calculated that roughly 25% of autopsies reveal a major diagnostic error, though that rate has decreased over time. A contemporary US institution can expect 8.4-24.4% of autopsies to detect major errors. One study that examined 694 diagnoses found that autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 cases of endocarditis. A study on patients who had been intubated found that abdominal conditions, specifically abscesses, bowel perforations, or infarction, were as common a source of major errors as pulmonary emboli, and that even when patients complained of abdominal pain, the examination results were generally considered unremarkable and the symptom was not pursued further.

  In 2004 in England and Wales, there were 514,000 deaths. Of those, 225,500 were referred to a coroner. Of that group, 115,800, representing 22.5% of all deaths, resulted in a post-mortem examination. There were also 28,300 inquests that year, 570 of which included a jury. A study focused specifically on heart attacks as a cause of death found significant errors in both directions: a substantial number of deaths attributed to myocardial infarctions were not, in fact, caused by them, and a significant number of deaths not attributed to myocardial infarctions actually were.